Overuse, no diagnosis, no preventer: asthma habits revealed

asthma reliever puffer on its side

People with asthma are overusing reliever medication, a new study has found – and one stakeholder says pharmacists are in an ideal position to spot them

A study from the Woolcock Institute of Medical Research and the University of Sydney revealed, for the first time, details around a “hidden” population of people who buy relievers over the counter. The study is published in BMJ Open.

More than two thirds of those surveyed overused their reliever, while in contrast a similar number did not use a preventer puffer regularly.

Almost 20% of people who bought their reliever without a prescription reported that they had not been diagnosed with asthma.

The researchers designed a real-world cross-sectional observational study in community pharmacy, and found that of 412 participants aged 16 and over requesting short-acting beta agonists OTC, 289 were overusers – that is, they used SABA more than twice a week in the past four weeks.

The researchers wrote that, “70.1% of participants were classified as SABA overusers, that is, reporting SABA use more than twice a week within the last 4 weeks, 73.6% reported not using a preventer daily and only 81.6% reported a doctor diagnosis of asthma.

“SABA overusers were more likely to have moderate-severe nasal symptoms (80.8% vs 63.0%, p<0.001) and a diagnosis of depression (11.1% vs 5.7%, p<0.001), when compared with SABA non-overusers.

“A higher proportion of SABA overusers had uncontrolled asthma (59.0% vs 15.4%, p<0.001), were more likely to use oral corticosteroids to manage worsening asthma symptoms (26.2% vs 13.5%, p<0.01) and visit the doctor for their asthma in the past 12 months (74.5% vs 62.5%, p<0.01), when compared to SABA non-overusers.

“This study uncovers a hidden population of people who can only be identified in pharmacy with suboptimal asthma, coexisting rhinitis, poor preventer adherence and, in some cases, no asthma diagnosis.”

“Results show our concerns about asthma management are real,” says Professor Sinthia Bosnic-Anticevich, senior author and head of the Woolcock’s Quality Use of Respiratory Medicines Group, an affiliate of the University of Sydney.

“The high proportion of reliever overuse and the low proportion of regular preventer use is in complete contrast to what we would hope to see.

 “It’s well established that one of the key signs of poor asthma symptom control is the need for frequent reliever use. This research indicates that this is common, yet patients don’t seem to be complaining.

“SABA overuse is very high, while preventer medication use remains low, a habit which can lead to poor outcomes and likely explains why only a quarter of over-the-counter purchasers reported well-controlled asthma,” Professor Bosnic-Anticevich says.

“When you consider that there are potentially tens of thousands of people using their medication like this, it suggests that a considerable proportion of Australians are experiencing wheezing, chest tightness and, worse still, asthma flare ups, due to uncontrolled disease.”

She says that SABA therapy should be carefully restricted to ‘as needed’ usage only.

“We know that using your reliever too much is linked to poor asthma control, increased airway hyper-responsiveness, more asthma-related hospital admissions and, in extreme cases, death,” Professor Bosnic-Anticevich says. “What we really need to understand is why this is happening.

“We absolutely don’t want to ask patients to withhold using their SABA if they need it, but we do need to solve the problem of why they need it or feel they need it,” she says. “It is critical that we support patients and work with them and their doctors to ensure that asthma flare ups are prevented, and overuse of SABA is not the answer.”

The researchers are calling for more work to explore ways in which community pharmacists can identify these uncontrolled asthma patients and refer them onto treatment plans that improve asthma outcomes.

Responding to the new data, Siobhan Brophy, CEO of the National Asthma Council, told the AJP that “This study shines a light on a potentially hidden group of people with poorly controlled asthma – those who rely on a SABA reliever to treat their asthma symptoms rather than taking a regular preventer to manage the underlying inflammation”.

“Pharmacists are ideally placed to identify patients who might be at risk of adverse outcomes through SABA overuse,” she says.

“For example, when dispensing a SABA, look for red flags by asking empathetically how many SABA puffers the patient has bought recently or how quickly they use up a puffer.

“The threshold for concern may be lower than you think – going through three canisters in a year averages out as more than 11 puffs a week.

“Patients shouldn’t avoid taking the SABA if they need it, however if red flags are noted it’s a good opportunity for pharmacists to work with the patient and their doctor to help address any underlying issues.”

She cited the Australian Asthma Handbook’s section on assessing use of short-acting beta2 agonist reliever to identify overuse:

  • Ask how many puffs taken per day.
  • Ask how long reliever puffer lasts.
  • Check prescribing records.
  • Ask if patient also uses non-prescription (‘over-the counter’) reliever.
  • Dispensing of three or more canisters in a year (average 1.6 puffs per day) is associated with increased risk of flare-ups. Dispensing 12 or more canisters in a year (average 6.6 puffs per day) is associated with increased risk of asthma death.

Ms Brophy says that upscheduling of salbutamol would not fix the problem.

“For example, there is evidence from other countries that overuse can also occur in settings where SABA is prescription only,” she told the AJP.

“And importantly, SABA is an essential rescue medication and should remain accessible for asthma first aid in the community.

“We are instead focussing on supporting pharmacists, GPs and patients to develop strategies that will connect people at risk of asthma with the health professionals who can help them address the problem.”

Recently Professor Andrew Bush, Department of Paediatric Respiratory Medicine at Royal Brompton Hospital, London, also highlighted SABA overuse and its role in asthma death.

“The blue inhaler is a killer; numerous asthma deaths occur in those who are using SABA for relief in increasing quantities but not using ICS,” he wrote in The Lancet Respiratory Medicine.

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  1. Jarrod McMaugh

    Pharmacists who are talking with a person that is requesting SABA as an OTC should get in to the habit of accessing MHR.

    There has been clear advice to pharmacists for years now that the purchase of OTC SABA should be accompanied with a discussion about technique and asthma plan (including preventer use). The advice has also included the need to get past the initial barrier to communication that is “oh yeah, I’ve used it before, I have a preventer at home” etc.

    When seeking permission to access the person’s MHR, you can readily see what their rate of purchasing a preventer indicates, and use this to guide the conversation.

    To reiterate again though – every supply of an pMDI should be accompanied with a discussion on technique, and every SABA supply should be accompanied with a discussion on preventer use/asthma plan. Assuming that a person is implementing best treatment (regardless of their level of understanding) isn’t what we are here to do….. facilitating best possible function is.

    • Andrew

      Tbh, the typical markup on an OTC SABA makes this kind of interaction difficult. For a profit of a couple of bucks you’re tying up a pharmacist for at least five minutes. Even promoting it as a “loss leader” would be charitable, it’s certainly not sustainable.

      • Jarrod McMaugh

        The pharmacist has a professional obligation to ensure QUM.

        If the proprietor doesn’t value the service provided by their staff by covering this time in the price to the client, then they should re-examine their pricing structure.

        If the proprietor limits the professional role of the pharmacist delivering that service, they should be reported to AHPRA.

        To put it in terms that you would relate to:

        “After all, if we’re not focussing on the best outcomes for public health regardless of stakeholders what’s the point?
        I think you’ll find most pharmacists would agree that the pharmacy model in Australia has stagnanted and that better outcomes can be achieved, but that the govt funding for services and research is so locked in to the retail model that the spiral of diminishing returns is likely to continue, for at least another five years.”

        If the concern is about the markup rather than the outcome, no wonder here is stagnation…..

        • Andrew

          I’m entirely out of the game Jarrod – just commenting on the commerical reality of what you’re suggesting. I never had the luxury of being an owner, I always had to report to someone more interested in buying this year’s Mercedes than health outcomes. Gotta pay them bills so had to toe the line, until I GTFO. I feel less dirty now, but only slightly

  2. Bruce ANNABEL

    I think pharmacists helping patients who suffer from asthma is a good idea. And I hope it becomes reality one day. Since Ventolin came to market in Australia in, from memory, the late 60’s or early 70’s I have been using it and it’s wonderful product that has saved my life several times. However, the only pharmacy interaction I have had in that time is supply, would you like the cheaper option and cash and wrap. The pharmacist who takes an interest in my condition helping with management and lifestyle issues will likely see me return, have my scripts filled and buy other health/medicine lines. The point is the happy returning patient is worth much more than a simple transaction.

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